J-2_QASP.pdf

HSCEDM-16-R-00002

Amendment 12

J-2 – Quality Assurance Surveillance Plan (QASP)

Functional Area

Performance Requirements

Performance Measure

Method of Surveillance

Acceptable Quality Level

Deduction or Withholding Criteria

Staffing*

Vendor shall have scheduled* and working* on-site*, 100% of the position codes listed in J-1-Site Staffing Matrix and as updated in future contract modifications.

according to J-3– Position Descriptions.

The count of the number of position codes listed as vacant or filled as per J-11- Site Status Report

An employee shall keep the same position code for the duration they are employed on the contract unless otherwise approved in writing by the Contracting Officer’s Representative.

No other criteria other than filled, vacant, as per J- 11 Site Status Report is used to describe the status of a position code.

Unfilled position codes-due to a contract modification, will be exempt from assessment for 45 days from the date of modification, On day 46 it will be reported as filled or vacant on the J-11 Site Status Report.

J-11-Site Status Report. Vendor shall provide the competed report to the government weekly.

Other methods of surveillance may be used.

100% of position codes at each site as per J-11-Site Status Report will be scheduled and working on-site.

Contractor must submit a waiver for consideration to the COR/CO to fill a vacant full time position code with part time or temporary staff (multiple or single employee).

Waivers will be evaluated on a case by case basis and shall not exceed 60 days without written permission from the COR/CO.

No site may exceed 20% part time or temporary assigned staff at any given time.

The monthly amount invoiced per site will be reduced by the sum of deductions applicable to each labor category at that site.

LVN/LPNs < 85% = 0.25% < 80% = 0.50% < 75% = 1.00% <XX%=5.00% - See Site Specific Critical Staffing Level- QASP Appendix I

RNs < 88% = 0.25% < 83% = 0.50% < 78% = 1.00% <XX%=5.00% - See Site Specific Critical Staffing Level- QASP Appendix I

MLPs < 90% = 0.25% < 83% = 0.50% < 78% = 1.00% <XX%=5.00% - See Site Specific Critical Staffing Level- QASP Appendix I

MHPs < 90% = 0.25% < 83% = 0.50% < 78% = 1.00% <XX%=5.00% - See Site Specific Critical Staffing Level- QASP Appendix I

Techs/Assistants < 92% = 0.25% < 87% = 0.50% < 82% = 1.00% <XX%=5.00% - See Site Specific Critical Staffing Level- QASP Appendix I

MD/DO-DDS-Pharm < 75% = 0.25% <XX%=5.00% - See Site Specific Critical Staffing Level- QASP Appendix I

Attachment J-2 QASP

Performance Requirements

Performance Measure

Method of Surveillance

Acceptable Quality Level

Deduction or Withholding Criteria

Site Specific Critical levels for each facility are identified on the QASP Appendix 1.

e-QIP Submission for

Contract Modification

Staff

Additions

Vacancy

The Contractor will have thirty (30) calendar days from the date of the fully executed contract modification, or effective date of a vacancy, to submit an e-QIP initiation request (with position code) for qualified candidates for those positions.

The e-QIP Submission, and Start Date Functional Area timelines are applicable thereafter to staff added under a contract modification, or vacancy.

The number of calendar days from the date of the fully executed contract modification, or vacancy, until the submission of e- QIP initiation request for qualified candidates for those positions.

J-11-Site Status Report. Vendor shall provide the competed report to the government weekly.

Other methods of surveillance may be used.

100% of contract modification staff additions, or vacancies, will have e-QIP initiation requests submitted for qualified candidates within thirty (30) calendar days.

Metrics will be reported in

CPARS.

Backfill* For

Nursing Staff

The Contractor will provide RN and LVN/LPN backfill for contractor Shift-Call-Out’s*

Count of the number of Shift - Call Out’s successfully and unsuccessfully backfilled.

A Call Out shift will be considered successfully backfilled if 50% of that shift has been staffed

J-11-Site Status Report. Vendor shall provide the completed report to the government weekly.

Other methods of surveillance may be used.

100% of Shift - Call Out’s requiring backfill will receive backfill.

Performance Requirements

Performance Measure

Method of Surveillance

Acceptable Quality Level

Deduction or Withholding Criteria e-QIP Submission

Vendor shall ensure candidate submits a complete (no missing standard documentation) e- QIP security packet (electronic and hard copy) to the IHSC COR within ten (10) calendar days after receiving notice of e-QIP initiation.

Hard copy e-QIP packets will be mailed to the IHSC COR utilizing a mail tracking method through the U.S.P.S, FedEx, UPS or other service provider of equal scope and ability.

Number of complete (no missing standard documentation) e- QIP packets received by the IHSC COR within ten (10) calendar days of notification of e- QIP initiation.

J-11-Site Status Report. Vendor shall provide the competed report to the government weekly.

Other methods of surveillance may be used.

100% of candidates submit complete electronic and hard copy e-QIP (security) packets to the IHSC COR s within ten (10) calendar days after receiving notice of e-QIP initiation.

Start Dates

Contractor shall ensure staff are on-site and working (start date) within thirty (30) calendar days of notification of initial favorable fitness determination.

Exceptions may be granted on a case by case basis, only if approved in writing by COR.

Number of calendar days between notification of initial favorable fitness determination and when that employee is on-site and working.

J-11-Site Status Report. Vendor shall provide the competed report to the government weekly.

Other methods of surveillance may be used.

100% of start dates (on-site and working) shall occur within thirty (30) calendar days of notification of initial favorable fitness determination.

Credentialing

The Vendor shall submit, to on-site Key Personnel, and for the Government Technical Monitors review, a complete credentialing packet for each employee hired, no less than three (3) calendar days before the employee is on-site and working.

The number of complete and incomplete credentialing packets received, no less than three calendar days before the employee is on-site and working.

Government Technical Monitor will review credentialing packet documentation received from the vendor through on-site Key Personnel each month.

Government Technical Monitor will document and report their findings to the COR’s via

100% of credentialing packets are complete when reviewed by the Government Technical Monitor Prior to the start of contract staff.

Performance Requirements

Performance Measure

Method of Surveillance

Acceptable Quality Level

Deduction or Withholding Criteria email.

Other methods of surveillance may be used.

Privileging* for Licensed Independent

Providers (LIP’s)

Contractor shall present the government with a complete privileging packet, as per J-6- Credentialing and Privileging, no less than ten (10) Business days before start date.

Number of complete and incomplete privilege application packets received ten (10) Business days before start date of candidate.

J-11-Site Status Report.

Contractor shall provide this competed report to the government weekly.

Other methods of surveillance may be used.

100%. The government will be provided a complete and accurate privileging application ten

(10) Business days prior to candidate’s start date.

Competency Assessment

(CA)

Vendor staff shall complete the Competency Assessment with no discrepancies between the PD performance requirements and actual demonstrated performance during the CA period within ten (10) working days.

Staff not successfully completing the CA will be not be considered as qualified.

Position codes assigned to staff unsuccessfully completing their CA will be considered as having been vacant as of the prior effective date of resignation or termination assigned to that position code.

Number of successful/ unsuccessful, discipline specific, competency assessments completed.

The Vendor shall report to the government on a weekly basis the status of their staff currently in the competency assessment period by name and position code. To include start date and scheduled end date of the assessment period.

Staff not completing the orientation and competency assessment will be clearly identified in J-11-Site Status Report.

Other methods of surveillance may be used.

100% of staff completing the competency assessment demonstrates no discrepancies between the PD performance requirements and actual demonstrated performance.

Deliverables

100% of deliverables in F-4 –

Date of receipt of deliverables and

E-mail receipt to IHSCCOR mailbox

100 % receipt of completed

< 100% compliance will result in 0.25%

Performance Requirements

Performance Measure

Method of Surveillance

Acceptable Quality Level

Deduction or Withholding Criteria

Deliverables Table will be completed by due date.

their corresponding due date.

or other method as required deliverables withholding of the entire monthly invoice.

1. The Contractor is responsible for performance of ALL terms and conditions of the contract. The performance measures outlined in this QASP will be used to determine Contractor performance in each Functional Area.

2. The Government performs surveillance to determine Contractor performance and guide the Contracting Officer as to withholding or deduction, if any. Withholdings or Deductions, when applied, will be a sum of applicable withholdings or deductions for each functional area.

3. Where an asterisk is present next to a word in the QASP there is a corresponding definition in Contract Section C-34 – Glossary, specific to the implementation of the QASP.

4. Within 48 hours of the occurrence of Critical-level deficient performance, the Contractor must provide a corrective action plan to the COR and Contracting Officer. During a period of Critical-level deficient performance, the Contractor will provide the COR and Contracting Officer daily updates describing all actions taken to address and correct the deficient performance, and the results of those actions. Upon providing notice to the Contractor, the Government may utilize all resources available, including other contractors, in order to fill critical-level staffing shortages until the government is satisfied that the Contractor is able to resume acceptable performance.

5. Funds may be deducted from a monthly invoice as per the QASP. The Contractor will be notified immediately if such a situation arises. The Contracting Officer in consultation with the ICE Program Office will determine the amount of any deduction.

The assessment of deductions does not preclude the Contracting Officer from initiating other applicable contract actions and remedies.

6. For facilities experiencing Critical staffing shortages, the Government may incur additional costs to transfer or re-locate, in-process, and house detainees in alternate facilities. For facilities with guaranteed minimum bed-space, in addition to the costs noted above, the Government will also incur costs for unused bed-space.

The following locations include guaranteed minimum bed-spaces:

Sites with Guaranteed Minimums Site Guaranteed Minimum

Alexandria 1,170 Buffalo (Batavia) 400

El Paso 650 Elizabeth 285 Florence 374 Houston 750

Jena 1,170 Krome 450 Pearsall 1,350

Port Isabel 800 Stewart 1,600 Tacoma 1,181

The Government retains the right to file claims against the Contractor for costs associated with unused bed-spaces which are directly associated with the Contractor’s Critical staffing levels.

7. For the purpose of this QASP, all Contractor staff at the Washington, D.C. location are assigned to the Assistants/Technician Staffing Category.

8. For Functional Areas noting CPARS reporting: (a) CPARS will be reported for the Contractor’s overall successes in maintaining acceptable quality levels; and (b) CPARS will be reported for the Contractor’s consistent or repeated failures to meet acceptable quality levels.

Definitions:

Critical: Staffing levels have dropped below levels required to maintain full compliance with American Correctional Association (ACA), National Commission on Correctional Healthcare (NCCH) standards, or Family Residential Standards. These staffing levels put the facilities at risk for reducing or suspending detainee intake, relocating detainee population or reducing services provided at the facility.

Deduction: Amount of monthly invoice reduction as the result of a deficiency. Amounts deducted are not recoverable.

Field positions: All positions, other than Headquarters positions located in Washington, DC.

Head Quarters (HQ): All Headquarters positions located in Washington DC.

Less Than Full Performance: Staffing levels have dropped below the optimal levels required to maintain full compliance with American Correctional Association (ACA), National Commission on Correctional Healthcare (NCCH) standards or Family Residential Standards (FRS). This level of performance negatively impacts morale for both the Contractor and Federal employees, and may also affect the quality of care at the sites. It is important that the contractor provide 100% staffing.

Withholding: Amount of monthly invoice payment withheld pending correction of a deficiency. Funds withheld from payment are recoverable if the COR and Contracting Officer confirm resolution/correction, and should be included in the next month’s invoice.